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eForm DBAP Types
by
plone
—
last modified
2007-06-18 14:31
Click here to get the file
File contents
<html>
<head>
<style type="text/css">
table {
font-size: 12;
font-family: Arial;
}
table.elements {
border-collapse: collapse;
margin-left: 10px;
margin-right: 10px;
}
table.elements td{
border: 1px solid grey;
padding: 2px;
//background-color: #F0F8FF;
}
table.elements th{
border: 1px solid grey;
padding: 0px;
}
</style>
</head>
<body>
<center><h3>EForm DBAP Types</h3></center>
<form method="POST" action=" savemyform.jsp?demographic_no=18&fid=221&form_name=EFMreference">
<table class="elements">
<tr><td>
oscarDB=patient_name
</td><td>
Last Name, First Name
</td><td>
<input type="text" name="one" size="20" oscarDB=patient_name value="ELDER,JUNE">
</td></tr>
<tr><td>
oscarDB=patient_nameL
</td><td>
Patient Last Name
</td><td>
<input type="text" name="two" size="20" oscarDB=patient_nameL value="ELDER">
</td></tr>
<tr><td>
oscarDB=patient_nameF
</td><td>
Patient First Name
</td><td>
<input type="text" name="two" size="20" oscarDB=patient_nameF value="JUNE">
</td></tr>
<tr><td>
oscarDB=today
</td><td>
Today's Date
</td><td>
<input type="text" name="four" size="20" oscarDB=today value="2005-08-31">
</tr></td>
<tr><td>
oscarDB=label
</td><td>
Patient's electronic label
</td><td>
<textarea rows="6" cols="20" name="five" oscarDB=label>ELDER,JUNE
456 Main Street
Toronto,ON,M6P 4J4
Home:416-555-6789
Work:
06/06/1937(F)
8888999904 ZE</textarea>
</tr></td>
<tr><td>
oscarDB=address
</td><td>
Patient's 3-line address
</td><td>
<textarea rows="6" cols="20" name="six" oscarDB=address>456 Main Street
Toronto,ON,M6P 4J4</textarea>
</tr></td>
<tr><td>
oscarDB=addressLine
</td><td>
Patient's address in one line
</td><td>
<input type="text" name="seven" size="30" oscarDB=addressLine value="456 Main Street, Toronto, ON, M6P 4J4">
</tr></td>
<tr><td>
oscarDB=province
</td><td>
Two-letter province code
</td><td>
<input type="text" name="eight" size="20" oscarDB=province value="ON">
</tr></td>
<tr><td>
oscarDB=doctor
</td><td>
Name of the patient's doctor
</td><td>
<input type="text" name="nine" size="20" oscarDB=doctor value="Welby, Marcus (DRW)">
</tr></td>
<tr><td>
oscarDB=DOB
</td><td>
Date of birth - includes format text
</td><td>
<input type="text" name="ten" size="20" oscarDB=DOB value="06/06/1937 (d/m/y)">
</tr></td>
<tr><td>
oscarDB=DOBc
</td><td>
Plain date of birth (no format text)
</td><td>
<input type="text" size="20" name="eleven" oscarDB=DOBc value="1937/06/06">
</tr></td>
<tr><td>
oscarDB=NameAddress
</td><td>
Patient's name and then 2-line address
</td><td>
<textarea rows="4" cols="20" name="twelve" oscarDB=NameAddress>JUNE ELDER
456 Main Street
Toronto,ON,M6P 4J4</textarea>
</tr></td>
<tr><td>
oscarDB=Email
</td><td>
Patient's e-mail address
</td><td>
<input type="text" size="20" name="thirteen" oscarDB=Email value="june@oscar.com">
</tr></td>
<tr><td>
oscarDB=HIN
</td><td>
HIN with version code
</td><td>
<input type="text" size="20" name="fourteen" oscarDB=hin value="8888999904 ZE">
</tr></td>
<tr><td>
oscarDB=HINc
</td><td>
HIN (no version code)
</td><td>
<input type="text" size="20" name="fifteen" oscarDB=HINc value="8888999904">
</tr></td>
<tr><td>
oscarDB=HINversion
</td><td>
Version code of HIN
</td><td>
<input type="text" size="20" name="sixteen" oscarDB=HINversion value="ZE">
</tr></td>
<tr><td>
oscarDB=phone
</td><td>
Phone #1 as appears in the database
</td><td>
<input type="text" size="20" name="seventeen" oscarDB=phone value="416-555-6789">
</tr></td>
<tr><td>
oscarDB=phone2
</td><td>
Phone #2 as appears in the database
</td><td>
<input type="text" size="20" name="eighteen" oscarDB=phone2 value="555-555-5123">
</tr></td>
<tr><td>
oscarDB=clinic_name
</td><td>
Name of the clinic (May not be set in properties)
</td><td>
<input type="text" size="20" name="nineteen" oscarDB=clinic_name value="Stonechurch Family Health Center">
</tr></td>
<tr><td>
oscarDB=clinic_phone
</td><td>
Phone of the clinic as set in the properties file.
</td><td>
<input type="text" size="20" name="twenty" oscarDB=clinic_phone value="555-555-5555">
</tr></td>
<tr><td>
oscarDB=clinic_fax
</td><td>
Clinic fax number
</td><td>
<input type="text" size="20" name="tone" oscarDB=clinic_fax value="555-555-5555">
</tr></td>
<tr><td>
oscarDB=clinic_label
</td><td>
</td><td>
<textarea rows="6" cols="20" name="ttwo" oscarDB=clinic_label>Stonechurch Family Health Center
589 Stonechurch Rd E
Hamilton,Ontario,L8M 4R6
Home:555-555-5555
Fax:555-555-5555
</textarea>
</tr></td>
<tr><td>
oscarDB=clinic_addressLine
</td><td>
Clinic street address only
</td><td>
<input type="text" size="20" name="tthree" oscarDB=clinic_addressLine value="589 Stonechurch Rd E"></textarea>
</tr></td>
<tr><td>
oscarDB=clinic_addressLineFull
</td><td>
Full clinic address (with postal code, province)
</td><td>
<input type="text" size="20" name="tfour" oscarDB=clinic_addressLineFull value="589 Stonechurch Rd E, Hamilton, Ontario, L8M 4R6"></textarea>
</tr></td>
<tr><td>
oscarDB=clinic_address
</td><td>
Address of the clinic
</td><td>
<textarea rows="3" cols="20" name="tfive" oscarDB=clinic_address>589 Stonechurch Rd E
Hamilton,L8M 4R6
Ontario,Canada</textarea>
</tr></td>
<tr><td>
oscarDB=Social_Family_History
</td><td>
From eChart
</td><td>
<textarea rows="2" cols="20" name="tfive2145" oscarDB=Social_Family_History>Mother had Alzheimer's on set
at age 70
"Family History Notes XXX"
"Spouse was Heavy Smoker" -JC
"Second Hand Smoke" - DRW</textarea>
</tr></td>
<tr><td>
oscarDB=Other_Medications_History
</td><td>
From eChart
</td><td>
<textarea rows="2" cols="20" name="tfive21255" oscarDB=Other_Medications_History>other medications</textarea>
</tr></td>
<tr><td>
oscarDB=Medical_History
</td><td>
From eChart
</td><td>
<textarea rows="2" cols="20" name="hist121255" oscarDB=Medical_History>Tonsils and Adenoids, removed
when 8 years old
PM/S Hx Note XXX</textarea>
</tr></td>
<tr><td>
oscarDB=OngoingConcerns
</td><td>
From eChart
</td><td>
<textarea rows="2" cols="20" name="Ongs" oscarDB=OngoingConcerns>250(NIDMM) (adverse effect of drugs)
</textarea>
</tr></td>
<tr><td>
oscarDB=Reminders
</td><td>
From eChart
</td><td>
<textarea rows="2" cols="20" name="rem2215" oscarDB=Problem_List></textarea>
</tr></td>
<tr><td>
oscarDB=age
</td><td>
Patient Age
</td><td>
<input type="text" size="20" name="age215" oscarDB=age value="68">
</tr></td>
<tr><td>
oscarDB=sex
</td><td>
M/F
</td><td>
<input type="text" size="20" name="sex24" oscarDB=sex value="F">
</tr></td>
<tr><td>
oscarDB=provider_name
</td><td>
Name of the provider (Who is currently logged in)
</td><td>
<input type="text" size="20" name="provide2024215" oscarDB=provider_name value="Paul, Adoc">
</tr></td>
</table>
<input type="submit">
</form>
</body>
</html>